Provider Demographics
NPI:1114646205
Name:BOOTHE, ANNE C (LP)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:C
Last Name:BOOTHE
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:
Other - Last Name:KOSTIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:2311 ENERGY DR BLDG 9
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-4343
Practice Address - Country:US
Practice Address - Phone:984-254-5635
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6000103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist